Provider Demographics
NPI:1376895540
Name:ROACH, KIMBERLY REY (LMT, L/OTR)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:REY
Last Name:ROACH
Suffix:
Gender:F
Credentials:LMT, L/OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10502 NW 47TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-7835
Mailing Address - Country:US
Mailing Address - Phone:352-222-3409
Mailing Address - Fax:
Practice Address - Street 1:250 NW 76TH DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-6668
Practice Address - Country:US
Practice Address - Phone:352-505-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA67664225700000X
FL17463225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist